Chronic Urticaria Clinical Presentation

  • Author: Daniel J Hogan, MD; Chief Editor: William D James, MD   more...
 
Updated: Nov 18, 2011
 

History

An important historical characteristic of urticarial lesions is their transient nature. An individual wheal typically lasts for less than 24 hours. Pruritus is the most common associated symptom. If lesions last longer and are associated with pigmentary changes or symptoms (eg, pain or burning), consider performing a biopsy to exclude urticarial vasculitis.

Individual wheals last less than 1 hour in persons with physical urticaria, except for delayed pressure urticaria, in which individual wheals last at least 8-48 hours, especially on the palms and soles.

Next

Physical

The typical lesion of urticaria is a pale-to-red, well-demarcated papule or plaque. Lesions may be round, oval, annular, arcuate, serpiginous, or generalized. They resolve without postinflammatory pigmentary changes or scaling. Note the following:

  • Primary lesion: They are edematous erythematous papules or plaques with a pale center (wheal) and surrounding erythema (flare).
  • Distribution of lesions: Lesions can be localized or generalized.
  • Color of lesions: Depending on background skin color, lesions may be pale to red.
  • Differentiation: Stroking the skin firmly tests for symptomatic dermatographism. Exercise testing can confirm cholinergic urticaria. Application of an ice cube to the skin may test for cold urticaria.
Previous
Next

Causes

A number of factors have been reported to cause chronic urticaria, and these include the following:

  • Medications: Urticaria may be caused or exacerbated by a number of drugs. More common culprits include aspirin, other nonsteroidal anti-inflammatory drugs, opioids, ACE inhibitors, and alcohol.
  • Contactants: Contact urticaria syndrome refers to the onset of urticaria within 30-60 minutes of contact with an inciting agent. The lesions may be localized or generalized. Precipitating factors include latex (especially in health care workers), plants, animals (eg, caterpillars, dander), medications, and food (eg, fish, garlic, onions, tomato).
  • Foods and food additives: Some patients report the onset of acute urticaria associated with the consumption of certain foods, such as shellfish, eggs, nuts, strawberries, or certain baked goods.
  • Arthropod assault: Arthropod assault is the most common cause of papular urticaria. Although patients who are bitten by mosquitoes are likely to be aware of the source of the problem, patients with scabies, bedbug bites, flea bites, or other similar problems may not be aware. Ask patients about exposure to animals, recent moves, hobbies, travel, or the presence of a similar skin condition in other members of the household.
  • Infections: Urticaria has been reported to be associated with a number of infections; however, these associations are not strong and may be spurious. Infectious agents reported to cause urticaria include hepatitis B virus, Streptococcus and Mycoplasma species, Helicobacter pylori,[8, 9] Mycobacterium tuberculosis, and herpes simplex virus.
  • Autoimmune disease: Urticaria has been associated with a number of autoimmune diseases, including systemic lupus erythematosus, cryoglobulinemia, juvenile rheumatoid arthritis, and autoimmune thyroid disease, including Graves disease.[10, 11] Patients may be euthyroid but respond to replacement therapy or may respond to treatment of hyperthyroidism with carbimazole.
  • Autoinflammatory diseases: Urticaria is a feature of Muckle-Wells syndrome (amyloidosis, nerve deafness, and urticaria) and Schnitzler syndrome[12] (fever, joint/bone pain, monoclonal gammopathy, and urticaria).
  • Malignancies: Little evidence exists to support the concern that chronic urticaria is a cutaneous sign of occult internal malignancy. In a study of 1155 patients with chronic urticaria in Sweden, Sigurgeirsson found no association with cancer, although acquired angioedema associated with C1 inhibitor depletion may be associated with malignancy.[13]
  • Physical factors: Physical factors are the most commonly identified etiologies of chronic urticaria, accounting for approximately 20% of cases. The various types of physical urticaria are diagnosed by challenge testing. Several types exist, and finding that a single patient has more than 1 type is not uncommon. Below is a list of some types of physical urticaria and their causes:
    • Dermatographism/dermographism - Firm stroking
    • Delayed pressure urticaria - Pressure
    • Cold urticaria - Cold
    • Aquagenic urticaria - Water exposure
    • Cholinergic urticaria - Heat, exercise, or stress
    • Solar urticaria - Sun exposure
    • Vibratory urticaria - Vibration
  • Neurologic factors: An Italian study reported an association between chronic urticaria and fibromyalgia. The authors proposed that chronic urticaria is a consequence of fibromyalgia-neurogenic skin inflammation.[14]
  • Emotional factors: Psychological factors are reported to play a role in a number of patients. Reports exist of improvement of symptoms using hypnotism; however, the role of emotional factors remains controversial.
  • Genetic: Hereditary angioedema is characterized by recurrent attacks of angioedema (without urticaria) involving the skin, GI tract, respiratory tract, and mucous membranes in a patient with a positive family history. The disorder is autosomal dominant, and it is caused by a functional deficiency of the C1 inhibitor protein.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Daniel J Hogan, MD  Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Warren R Heymann, MD  Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Dr Dina Strachan, to the development and writing of this article.

References

  1. Tong LJ, Balakrishnan G, Kochan JP, Kinet JP, Kaplan AP. Assessment of autoimmunity in patients with chronic urticaria. J Allergy Clin Immunol. Apr 1997;99(4):461-5. [Medline].

  2. Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. Jun 2009;39(6):777-87. [Medline].

  3. Bossi F, Frossi B, Radillo O, et al. Mast cells are critically involved in serum-mediated vascular leakage in chronic urticaria beyond high-affinity IgE receptor stimulation. Allergy. Dec 2011;66(12):1538-1545. [Medline].

  4. Mathelier-Fusade P. Drug-induced urticarias. Clin Rev Allergy Immunol. Feb 2006;30(1):19-23. [Medline].

  5. Yosipovitch G, Greaves M. Chronic idiopathic urticaria: a "Cinderella" disease with a negative impact on quality of life and health care costs. Arch Dermatol. Jan 2008;144(1):102-3. [Medline].

  6. O'Donnell BF, Lawlor F, Simpson J, Morgan M, Greaves MW. The impact of chronic urticaria on the quality of life. Br J Dermatol. Feb 1997;136(2):197-201. [Medline].

  7. Maurer M, Ortonne JP, Zuberbier T. Chronic urticaria: a patient survey on quality-of-life, treatment usage and doctor-patient relation. Allergy. Apr 2009;64(4):581-8. [Medline].

  8. Tebbe B, Geilen CC, Schulzke JD, Bojarski C, Radenhausen M, Orfanos CE. Helicobacter pylori infection and chronic urticaria. J Am Acad Dermatol. Apr 1996;34(4):685-6. [Medline].

  9. Valsecchi R, Pigatto P. Chronic urticaria and Helicobacter pylori. Acta Derm Venereol. Nov 1998;78(6):440-2. [Medline].

  10. Heymann WR. Chronic urticaria and angioedema associated with thyroid autoimmunity: review and therapeutic implications. J Am Acad Dermatol. Feb 1999;40(2 Pt 1):229-32. [Medline].

  11. Bansal AS, Hayman GR. Graves disease associated with chronic idiopathic urticaria: 2 case reports. J Investig Allergol Clin Immunol. 2009;19(1):54-6. [Medline].

  12. Baty V, Hoen B, Hudziak H, Aghassian C, Jeandel C, Canton P. Schnitzler's syndrome: two case reports and review of the literature. Mayo Clin Proc. Jun 1995;70(6):570-2. [Medline].

  13. Sigurgeirsson B. Skin disease and malignancy. An epidemiological study. Acta Derm Venereol Suppl (Stockh). 1992;178:1-110. [Medline].

  14. Torresani C, Bellafiore S, De Panfilis G. Chronic urticaria is usually associated with fibromyalgia syndrome. Acta Derm Venereol. 2009;89(4):389-92. [Medline].

  15. Kanazawa K, Yaoita H, Tsuda F, Okamoto H. Hepatitis C virus infection in patients with urticaria. J Am Acad Dermatol. Aug 1996;35(2 Pt 1):195-8. [Medline].

  16. Dreyfus DH, Schocket AL, Milgrom H. Steroid-resistant chronic urticaria associated with anti-thyroid microsomal antibodies in a nine-year-old boy. J Pediatr. Apr 1996;128(4):576-8. [Medline].

  17. Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau A, et al. EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy. Oct 2009;64(10):1417-26. [Medline].

  18. Staevska M, Popov TA, Kralimarkova T, Lazarova C, Kraeva S, Popova D, et al. The effectiveness of levocetirizine and desloratadine in up to 4 times conventional doses in difficult-to-treat urticaria. J Allergy Clin Immunol. Mar 2010;125(3):676-82. [Medline].

  19. Morgan M, Khan DA. Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1. Ann Allergy Asthma Immunol. May 2008;100(5):403-11; quiz 412-4, 468. [Medline].

  20. [Guideline] Powell RJ, Du Toit GL, Siddique N, et al. BSACI guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy. May 2007;37(5):631-50. [Medline].

  21. Zuberbier T, Maurer M. Urticaria: current opinions about etiology, diagnosis and therapy. Acta Derm Venereol. 2007;87(3):196-205. [Medline].

  22. [Guideline] Grattan CE, Humphreys F. Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol. Dec 2007;157(6):1116-23. [Medline].

  23. [Guideline] American Academy of Allergy, Asthma & Immunology. Consultation and referral guidelines citing the evidence: how the allergist-immunologist can help. J Allergy Clin Immunol. Feb 2006;117(2 Suppl Consultation):S495-523. [Medline].

  24. [Guideline] American College of Allergy, Asthma, & Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol. Mar 2006;96(3 Suppl 2):S1-68. [Medline].

  25. Egan CA, Rallis TM. Treatment of chronic urticaria with ketotifen. Arch Dermatol. Feb 1997;133(2):147-9. [Medline].

  26. Jauregui I, Ferrer M, Montoro J, et al. Antihistamines in the treatment of chronic urticaria. J Investig Allergol Clin Immunol. 2007;17 Suppl 2:41-52. [Medline].

  27. Grob JJ, Auquier P, Dreyfus I, Ortonne JP. How to prescribe antihistamines for chronic idiopathic urticaria: desloratadine daily vs PRN and quality of life. Allergy. Apr 2009;64(4):605-12. [Medline].

  28. Ellis MH. Successful treatment of chronic urticaria with leukotriene antagonists. J Allergy Clin Immunol. Nov 1998;102(5):876-7. [Medline].

  29. Spector S, Tan RA. Antileukotrienes in chronic urticaria. J Allergy Clin Immunol. Apr 1998;101(4 Pt 1):572. [Medline].

  30. Papadopoulou N, Kalogeromitros D, Staurianeas NG, Tiblalexi D, Theoharides TC. Corticotropin-releasing hormone receptor-1 and histidine decarboxylase expression in chronic urticaria. J Invest Dermatol. Nov 2005;125(5):952-5. [Medline].

  31. Sahiner UM, Civelek E, Tuncer A, Yavuz ST, Karabulut E, Sackesen C, et al. Chronic urticaria: etiology and natural course in children. Int Arch Allergy Immunol. 2011;156(2):224-30. [Medline].

  32. [Medline].

  33. Brodell LA, Beck LA. Differential diagnosis of chronic urticaria. Ann Allergy Asthma Immunol. Mar 2008;100(3):181-8; quiz 188-90, 215. [Medline].

  34. Charlesworth EN. Urticaria and angioedema: a clinical spectrum. Ann Allergy Asthma Immunol. Jun 1996;76(6):484-95; quiz 495-9. [Medline].

  35. Grattan CE, Francis DM, Slater NG, Barlow RJ, Greaves MW. Plasmapheresis for severe, unremitting, chronic urticaria. Lancet. May 2 1992;339(8801):1078-80. [Medline].

  36. Greaves M. Chronic urticaria. J Allergy Clin Immunol. Apr 2000;105(4):664-72. [Medline].

  37. Greaves MW, Tan KT. Chronic urticaria: recent advances. Clin Rev Allergy Immunol. Oct 2007;33(1-2):134-43. [Medline].

  38. Haas N, Toppe E, Henz BM. Microscopic morphology of different types of urticaria. Arch Dermatol. Jan 1998;134(1):41-6. [Medline].

  39. Jorizzo JL, Smith EB. The physical urticarias. An update and review. Arch Dermatol. Mar 1982;118(3):194-201. [Medline].

  40. Kaplan AP. Clinical practice. Chronic urticaria and angioedema. N Engl J Med. Jan 17 2002;346(3):175-9. [Medline].

  41. Kennedy MS. Evaluation of chronic eczema and urticaria and angioedema. Immunol Allergy Clin NA. 1999;19:19-33.

  42. Komarow HD, Metcalfe DD. Office-based management of urticaria. Am J Med. May 2008;121(5):379-84. [Medline].

  43. Mahmood T. Physical urticarias. Am Fam Physician. May 1 1994;49(6):1411-4. [Medline].

  44. Schocket AL. Chronic urticaria: pathophysiology and etiology, or the what and why. Allergy Asthma Proc. Mar-Apr 2006;27(2):90-5. [Medline].

  45. Tharp MD. Chronic urticaria: pathophysiology and treatment approaches. J Allergy Clin Immunol. Dec 1996;98(6 Pt 3):S325-30. [Medline].

  46. Weston WL, Badgett JT. Urticaria. Pediatr Rev. Jul 1998;19(7):240-4. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.